Direction of change in surgery

Which is the direction of change in surgery? In so far as simple answers can be offered I believe these things are important. What can be done with less trauma, less blood loss, less suturing and less time is to be preferred. Prefer also that which causes less pain, illness and discomfort to the patient. It is noted that the doings of the surgical team and how the patient experiences the operation is focused, not the outcome.

The surgical act is focused on the assumption that the result stands proportional to how well the operation was conducted. I wonder if all surgeons believe this to be true. If they did so much of surgery would be different. Surgeons would search for simplicity and economy of the surgical act and hate everything that increases the complexity. They would avoid drains and nasogastric tubes and throw away retention sutures. They would switch to single layer anastomoses and change to a running suture with a single knot for the obvious reason that it is easier and saves time.

Surgeons would wonder why patients become ill after surgery and bedridden with pain. It cannot be blamed on the anaesthesia but rather on the surgery. Surgeons would find means to accomplish a bloodless and transfusion free surgery because bleeding and transfusion cause systemic effects. They would find means of a tension-free surgery because excessive suture and suture under tension induce ischaemic inflammation which is painful and trigger systemic responses.

Surgeons would master the use of their instruments so tissues can be cut and joined with the least of movements and force, and they would sharpen their minds to the point when the handicraft is nothing but the conception of the completed operation.

Above all, surgeons must acquire a clear understanding of the direction of change and the ways to promote it. There will be a day when surgery is done almost without patients suffering from it.

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I think there are 2 (or more) directions in surgery:
1. Less is more, that is, you can achieve better results with less (less sutures in the anastomosis, etc.)
2. Technical excellence and attention to detail makes all the difference in the outcome (this is an old finding, but bears repeating since it is often forgotten)–again nicely summarized
3. Pushing the limits of what is possible: Liver transplantation for bleeding varices or small hepatocellular cancer especially in cirrhotics, liver tranplantation without blood transfusion, regional transplants (liver, pancreas, small bowel and/or kidney) (Can you tell I just finished the Selected Readings Continuing ED in Liver Transplantation?)

So, I think there are basically 2 directions, less tubes, sutures, incisions, less operations, more endoscopy and pushing the limits to maximal tolerated surgery well beyond what any of us would have considered possible even 10 years ago.

I have the feeling, more than that,I have the convincement that in the message there,s a very singular and deep thought related with the future of surgery. He asks,what is the direction of change in surgery? I strongly believe that surgical attitudes,techniques,aims,etc., will really be modified when we’ll get to discover many facts that today remain in the obscure space of empirism (and that’s the princpal reason why dogmas tend to persist).As scientifical research goes in progression,the most probable fact that will take place in the years to come,regarding to surgery, is that this (surgery) will tend to dissapear slowly but persistently ’cause the management of many diseases that now require surgical actions will be changed by others not cruent. The surgical actions to persist will be those related with trauma, transplantation and reconstruction. These are the challenges for the future and in that sense we must regard changes. Can anybody go on believing that for a gastric mitosis, it’ll be always necessary to resect the whole stomach and all that is attached to it? It seems to me similar to something like this : “when somebody complaints of a headache,it’s necessary to cut his head off”.

Sometimes it is worth asking how a patient regards a good outcome to surgery. What, in their view, is a good surgeon? They probably ask:
1. Was I pain free after the operation?
2. Was the surgeon nice to me?
3. Did I get home quickly, free from complications?
4. Does the scar look nice?

Most patients have little or no idea exactly what went on inside them. They just see the scar on the outside. However if the surgeon does his job well then they can answer yes to the above questions and the outcome can be regarded as satisfactory. It is also worth asking if the surgeon has solved the problem which made the patient present in the first place.

I should like to remind all of us the difference between surgery and operation.

Surgery is the science and art of healing patients by the knife. When we read we are practicing surgery. When we take care of our patients in the office, or in the ward or in the ICU we are practicing surgery. We also practice surgery when we operate.

The operation is perhaps the acme of the practice of surgery, but it is just a small part of it.

Patients do not become ill after surgery. They become ill after operations.

I believe this distincition is more than semanthics. The distinction is important to the way we regard ourselves, and to how other health care professionals regard us.

Just to prove my point, take any textbook of surgery, and see how little in it is dedicated to the technical aspects of the operations that we do.

Quo vadis Surgery? When we see what has happened to us in these years being surgeons, we may say: a lot of water has passed under the bridge. When diagnosing a breast cancer, by early the 90’s, it meant wide radical mastectomy, with a horrible aesthetic effect, now in some cases we do a tumorectomy. What about surgical treatment of the peptic ulcer?, and nearer this time, what has happened with surg treat. of obstructive jaundice?, and so on, we may give a long list of diseases that are being treated with non surgical treatment. I guess that in the near future we’ll don’t operate cancer, I always have had the sensation that the surgical management of cancer is wrong, it’s too drastic ( have you seen a Hemipelviectomy?). So I think in the coming days surgery will be submited to trauma and just a little more. For transplantation, and malformation may be solved through another route, for example, Inmunology, molecular engineering, genetics,etc.

I agree with his philosophy, not necessarily every recommendation (I am not ready to throw away retention sutures, but I use them less and less). I admire he greatly and appreciate the learned advice.

My two cents worth: Surgery is an art of the mind, more than the hands, as our colleague physicians often fail to remember. So I hope that surgeons will continue to expand their academic acumen, so that the internist or the pediatrician does not feel obligated to rule out every possible diagnosis and refer to us only as a last resort. Rather, we should be trusted colleagues who can be counted upon to operate only when necessary, and relish the opportunity to solve a problem, with or without operating.

Also, over time, it seems, some diseases continue to require surgery, while others require less and less. Take appendicitis, for instance; this is a “surgical condition” for which there is no other cure; antibiotics are only a temporizing measure if you elect to perform an interval appendectomy. I see no alternatives on the horizon. Other diseases are found even more frequently in the OR because of improved diagnostic methods (CABG quadrupled since 1983…cholecystectomy tripled…Arch Surg ).

Peptic ulcer disease, on the other hand, is operated upon far less frequently than 25 years ago, partly because our understanding of the disease is much better (H. pylori, ZES, etc.) and partly because medical treatment is vastly better (H2 blockers, PPIs, etc). Nevertheless, we need to know what operation to do for varying ulcer problems, and be skilled in their application. Sometimes, it seems, the old becomes new again, as in the case of lung volume reduction surgery for bullous emphysema.

Which diseases of today will fall into the former or the latter category? Perhaps CABG will take a downturn in years to come due to improved lifstyles (smoking, exercise, diet) and treatment (HTN, DM, hyperlipidemia). Or will more single vessel disease be treated surgically instead of by PTCA as minimally invasive CABG becomes practically an outpatient procedure? IMHO, the former will be the case.

As HMOs pay less and less for procedures, will orthopedic surgeons relearn the art of casting? I think so. Will Nissen fundoplication become more popular as the long term benefits and lowered cost of the laprascopic variation become apparent? I think so. Will genetic therapy make some operations obsolete (imagine transfecting corrected copies of tumor suppressor genes to the mucosa of a dysplastic villous adenoma, instead of watching it become cancer) or be an indication for new operations (imagine implanting lab-cultured liver lobes which have the normal gene that’s missing in the host)? Yes to both.

Thanks for the thoughtful discussion about the principles of surgery. I will add bloodless, tension-free, and pain free to my list. I belileve that we are on this net to learn, and with that learning, allow all of us to move into the future as better surgeons. You have increased my knowledge. I do believe that there are some principles, at least in spirit, that are immutable. If ignored, the problems that plagued our surgical forefathers will befall us, and our patients, once again.